Example of a case conceptualization paper

Case Conceptualization Paper

Instructions for Case Conceptualization Paper

● Choose a client you are seeing and complete a case conceptualization ● Do NOT use the actual name of the client. Refer to the client as “the client”, the therapist

as “the therapist” and other people as their relationship to the client (the client’s brother, partner, daughter, etc.).

● The paper should be written in third person, e.g., “The client reported…”, “the client’s therapist emphasized…” “it is recommended...” and be professional in tone and language (not casual language

● All sections should be in narrative form and complete sentences (not bullets). ● Length: 10-13 pages (double-spaced), excluding title page and references page. Times

New Roman 12-size font, 1-inch margins all around. APA style.

Use the following sections to cover relevant content. Use these exact headings provided below:

1. Client demographics (age, gender, ethnicity, family composition and relations, living situation, employment [& history], education, sexual orientation, marital status, etc. Do NOT include clinical diagnosis information or symptom descriptions in this section). Suggested length: 1-2 paragraphs.

2. Clinical problems/symptoms and diagnoses of the client. Describe and discuss all presenting symptoms and count them against the DSM-5 criteria for specific disorders, making a judgment if the criteria are met and what are the likely DSM-5 diagnoses. You have to briefly list each of the criteria for the proposed disorders and explain how they are met or not met, providing examples from the client clinical picture. The emphasis is on explaining how the criteria are met, not listing the full criteria. Provide as complete diagnoses as possible. Include a history of symptom development and progress, if available. Discuss what additional information may need to be collected for alternative possible diagnoses to be ruled in or out, if relevant. Suggested length: 2 pages.

3. Pertinent clinical issues, such as social environment of the client, existence or lack of social support, relationships with significant others (family of origin and own family), cultural/diversity issues, client strengths, any complicating factors, and prognosis. Suggested length: About 1 page.

4. Cognitive Behavioral Case Formulation and Treatment Plan. Provide a case formulation and treatment plan for this client case. Your case formulation and treatment plan should be based on your own diagnosis and understanding and formulation of client problems, Do your best to write the CBT working

hypothesis section based on client info and typical cognitions for their disorder (do not omit or downplay this section, it is very important). Include suspected schemas, if information is not clear. Please also check relevant chapters or articles about CBT for OCD, Panic Disorder, etc. Suggested length: 3 pages.

5. Treatment depicted, therapeutic progress, and proposed interventions.

(a) Discuss and critique the treatment taken place with the client), Give details about techniques used and provide a critical examination of the process and outcome of treatment shown. Discuss client response to treatment and relevant obstacles. Comment on therapeutic relationship issues and note any difficulties. Suggested length: 2 pages.

(b) Discuss what additional or modified CBT or other interventions you would recommend, based on your case conceptualization and client response on interventions used in the video. Your interventions should cover all clinical issues, not just the primary diagnosis. Include both cognitive and behavioral techniques. Provide specific examples of the specific content of the interventions targeting specific content of client problems. For example, list what case-specific client negative distortions and thoughts need to be addressed and what the alternative, realistic thoughts would be. Also, what specific behavioral interventions will address specific client problems. Discuss how diversity or cultural factors affect treatment and how interventions may need to be adapted, if relevant to this client. Lastly, discuss the research/evidence base of your proposed interventions (with citations of research supporting the use of the specific intervention for the specific disorders). Suggested length: 2 pages.